Improving outcomes for children with malaria, diarrhoea and pneumonia in Mozambique through the inSCALE technology innovation: A cluster randomised controlled trial

Abstract

Background The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers. However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evaluated a technology-based intervention - inSCALE (Innovations At Scale For Lasting Effects) to support iCCM programmes and increase appropriate treatment and other outcomes for children with MDP. Methods This superiority cluster randomised controlled trial allocated all 12 districts in Inhambane Province in Mozambique to receive iCCM only (control) or iCCM plus the inSCALE technology intervention. The key components of the intervention consisted of a digital application on smartphones and tablets providing clinical decision support algorithms, stock tracking, automatic personalised messaging, free calls, and solar chargers for iCCM-trained community health workers and primary care facility supervising staff in intervention districts. Population surveys were conducted at baseline and after 18 months in all districts to assess the impact of the intervention on the coverage of appropriate treatment for malaria, diarrhoea and pneumonia in children 2-59months of age, on prevalence of cases of these conditions, and on a range of secondary household and health worker level outcomes. All statistical models accounted for the clustered study design and variables used to constrain the randomisation. A meta-analysis of the estimated pooled impact of the technology intervention was conducted including results from a sister trial (inSCALE-Uganda). Findings The study included 2740 eligible children in control arm districts and 2863 children in intervention districts. The prevalence of cases of MDP decreased from 53.5% (1467) to 43.7% (1251) in the control and intervention arms respectively (risk ratio 0.82, 95% CI 0.78-0.87, p<0.001). The rate of care seeking to the iCCM-trained community health worker increased in the intervention arm (14.4% vs 15.9% in control and intervention arms respectively) but fell short of the significance threshold (adjusted RR 1.63, 95% CI 0.93-2.85, p=0.085). Coverage of the appropriate treatment of cases of MDP increased by 26% in the intervention arm (RR 1.26 95% CI 1.12-1.42, p<0.001) after accounting for the randomisation and design effects. Across two country trials, the estimated pooled effect of the inSCALE intervention on coverage of appropriate treatment for MDP was RR 1.15 (95% CI 1.08-1.24, p <0.001). Interpretation The inSCALE intervention led to a reduction in prevalence of MDP and an improvement in appropriate treatment when delivered at scale in Mozambique. The programme will be rolled out by the ministry of health to the entire national CHW and primary care network in 2022. This study highlights the potential value of a technology intervention aimed at strengthening iCCM systems to address the largest causes of childhood morbidity and mortality in sub-Saharan Africa.